In preparation for the October 1 ICD-10 implementation deadline, the Centers for Medicare & Medicaid Services (CMS) have completed their third Medicare fee-for-service end-to-end testing with great success, according to a recent CMS report. This is the third successful CMS ICD-10 testing to occur in 2015.

The testing week, which occurred between July 20 and 24, included healthcare providers, clearinghouses, and billing agencies. These entities utilized the help of Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME) MAC Common Electronic Data Interchange (CEDI) to file their claims. Participants from previous tests were invited to partake in the July tests, thus bringing a considerable amount of returners to this session.

The July test was a success, according to CMS, with an 87 percent acceptance rate of the 29,286 claims received. The rejection rate for ICD-10 errors was 1.8 percent, and the rejection rate for ICD-9 errors was 2.6 percent. However, majority of rejected claims were not ICD-10 related. Among others, these included invalid NPIs, claims outside of the covered date range, and invalid place of service. CMS confirms that many of these same errors occurred in previous test sessions.

Additionally, CMS states that many rejected claims may have been submitted with errors on purpose. This practice, referred to as “negative testing,” is intended to ensure that CMS’ rejection processes are functioning properly and will indeed reject a provider’s invalid claim.

CMS reports a larger cross-section of volunteers this test session, with about 1,200 organizations selected to participate in the test. There were 493 organizations returning for previous tests. Additionally, 1,400 National Provider Identifiers (NPIs) participated in the test, and approximately 12 percent of those were repeats from prior tests.

This test brought about similar results to previous tests performed in January and April. In January, CMS reported an 81 percent approval rating between January 26 and February 3. This test included 661 volunteers. Just like this most recent test, the January test boasts a high success rate, with a majority of rejected claims resulting from non-ICD-10 related errors.

Tests performed in April were likewise successful. With 875 participants, CMS reported an 88 percent acceptance rate, which is consistent with the July tests. The number of rejections due to ICD-10 and ICD-9 errors are also consistent with the July tests, with a majority of rejections being due to other provider-related issues.

As providers and payers alike continue to prepare for the impending October 1 ICD-10 deadline, these test results bring promise to CMS. Not only have CMS’ systems shown a proven capability for accuracy, but they have shown consistent accuracy, with only a seven percent difference between the best and worst test performances. Provided these positive results, CMS has shown that it is ready for this new coding system.

The breach affected 3.9 million individuals, according to the Department of Health and Human Services'"wall of shame" website listing health data breaches affecting 500 or more individuals since September 2009.

In a July 30 statement, Indiana Attorney General Greg Zoeller said the cyberattack that was discovered in May affected an estimated 1.5 million individuals in Indiana alone. Zoeller is urging Indiana state residents to freeze their credit in the wake of the recent data breach at the Fort Wayne-based company.

Even if no other victims are identified, the cyberattack on MIE will be the seventh largest breach listed on the federal tally - and the fourth largest breach in 2015.

The other four larger breaches this year were also hacking attacks. Those include cyberattacks againstAnthem Inc., affecting nearly 80 million individuals; Premera Blue Cross, impacting 11 million; and UCLA Health, affecting 4.5 million.

In May, MIE revealed that a "sophisticated cyberattack" involving unauthorized access to its network began on May 7, resulting in a breach that compromised protected health information relating to patients affiliated with certain clients. At the time, the company named five healthcare entities that were among the affected clients and did not provide any estimate of how many individuals were impacted.

Updated Breach Details

An updated statement that MIE issued on July 24, however, shows the list of affected entities - ranging from small doctor offices to medical specialty group practices, hospitals and other organizations - has grown to more than 200.

The affected data relating to individuals who used a NoMoreClipboard portal/personal health record, the new statement notes, may include an individuals' name, home address, Social Security number, username, hashed password, spousal information - including name and potentially date of birth - security question and answer, email address, date of birth, health information and health insurance policy information.

MIE says that "out of an abundance of caution," it is offering affected individuals access to two years of free credit monitoring and identity protection services.

Steps to Take

Security expert Tom Walsh, founder of the consulting firm tw-Security, says he is startled by how many victims and entities are affected by the breach.

" I was surprised at the number of entities affected and the total number of patients. Some of those entities affected are located in Kansas, so I had heard about the breach through some of those organizations," says the consultant, whose company is based in Kansas. "All PHI data is a potential target. Obviously, we can and need to do a better job of protecting the data."

In the wake of the attack, healthcare organizations should take several steps protect EHRs, including cloud-based systems, Walsh says. Key action items include:

Patch management. Systems need to be evaluated and updated frequently.

Tighter access control. This is especially needed for system administrator access or elevated privileges, including employees, contractors and subcontractors. For example, two-factorauthentication should be required for any type of remote access.

Database encryption. Of course, this will only help if a hacker has not compromised a system administrator's account.

System monitoring. Consider outsourcing this activity to a third party using managed security services.

Enhanced incident response capability. The more exercise or drills that are conducted, the better the response when a real event occurs. Organizations should develop "playbooks" to document response procedures to the various scenarios.

MIE did not immediately respond to Information Security Media Group's request for comment.

Dismissing a team member, either for poor performance or financial reasons, is emotionally wrenching for all. In the best case scenario, it creates ill will for the terminated employee and anxiety for the staff members left behind. In the worst case, it can result in a patient mutiny, morale crisis, or legal claims.

To protect your practice and maintain a productive work environment, Ricki Roer, an attorney with Wilson Elser Moskowitz Edelman & Dicker in White Plains, N.Y., says leadership is imperative every step of the way. "The bottom line is that the physician owners are going to be the ones named in any lawsuits, so they must take full responsibility for the work environment they create, including termination sessions," she says. "Making sure that the employer is properly protected and fully assessing the decision to terminate is one of the great challenges for any employer, but it's even more so for physician owners because often their concentration is not in business or in creating a human resources apparatus within their business organization."

Here's how to fire a staff member the right way.

STEP 1: CONSIDER THE LEGAL ISSUES

Before a physician should even consider firing an employee, Roer says, they should carefully weigh whether a "legitimate business reason" exists for doing so — the standard defense against wrongful termination claims. Specifically, review the employee's file to determine whether he ever complained about unfair work practices, or indicated he was in need of accommodations related to religion or disability. Were such requests granted? Look, too, at the employee's written evaluation history. "Were they given wonderful rave reviews or top raises every year and does that in any way conflict with your stated reasons for articulating a legitimate business reason?" she says.

Consider, too, whether other employees who are "similarly situated," a legal term meaning those with a similar performance record, were treated differently, which could open the door to discrimination claims. And take note of whether the employee you are looking to fire falls into a protected employment category based on race, religion, gender, or age. Does any pattern of terminations within those categories exist, or appear to exist?

Most who work for physician practices are considered "at will" employees, says Roer. Thus, they can quit at any time without reason, and their employer may fire them without cause as well. Keep in mind, however, that the courts may consider any employee manuals you use or procedural processes for disciplinary action to be an "implied" contract, which could limit your ability to fire staff members at will.

Beyond exposure to claims of wrongful termination and discrimination, physicians are also uniquely vulnerable to legal accusations of false claims by disgruntled former employees. "This is an area where we've seen a huge increase," says Roer. "Ensure your practice does not in any way violate any of the guidelines for proper billing, because if there is a situation of any concern about compliance that opens the door to a disgruntled employee bringing up these issues and helping the government pursue a case." Whistleblowers are financially motivated to come forward, she says, because they get "a piece of the pie."

STEP 2: PREPARE FOR THE PROCESS

Once the decision to fire an employee is made, and all your legal bases are covered, the physician owner must decide who delivers the news. In larger practices, that may be the human resources supervisor or the employee's immediate supervisor. But a second manager, or the physician, should always be present to witness what was (and more importantly, was not) said. The physician owner should also ensure that all keys, phones, and laptops belonging to the office are turned over before the employee leaves, and that computer passwords to any software programs are immediately changed.

Throughout the termination process, it is important to show the employee the respect he deserves, both because it's the right thing to do and because it minimizes ill will, says Michael Munger, a family physician in Overland Park, Kan., and a director of the American Academy of Family Physicians. "It's important to do this privately, without a lot of bystanders," says Munger, noting it will cause less embarrassment to break the news when the fewest staff members are present — either at lunch, or at the end of the day. "Take them to a separate room and give the employee as much dignity as you can." Some HR experts suggest terminating staff early in the work week rather than on a Friday, giving them an opportunity to send out resumes right away rather than pondering their unemployment over the weekend. Either way, the employee's last day should be the same day she is terminated. Whatever is owed to her for the remaining pay period, or per her contract, must be paid in full, but you don't want an angry employee kicking around the office for the next two weeks.

STEP 3: REASSURE THE REMAINING STAFF

After the employee has left the office, the physician's role becomes central. "As the leader of the office, the physician owner needs to be the one communicating with the staff," says Munger. Don't let the news trickle out if you hope to manage morale.

Be sure, too, to address your staff personally rather than sending out an e-mail. "In a very straightforward way, tell them that this person is no longer part of our team, without divulging a lot of details, and immediately set to work planning for those job functions that need to be handled until their replacement is hired."

Take time specifically to address the concerns of your staff members. Be sure they understand that their own jobs are secure and that every effort was made to retain the staff member who was just let go. "Anytime a fellow coworker is no longer there that can lead to worry for their own job," says Munger. "In a doctor's office, you work together as a team so it affects everyone. It's really important to talk through their concerns and help develop an action plan together for how we're going to get the work covered."

There's no easy way to terminate an employee. By managing the process professionally and treating your staff member with dignity, however, you can minimize potential aftershocks. "The more attention and detail physician owners invest in a well-run professional work environment that is compliant and knowledgeable of all its obligations and duties, the better protected they are," says Roer. "That is a great investment of time as well as dollars."

The American Hospital Association (AHA) recently sent CMS their comments on the Stage 3 Meaningful Use proposed rule and explained that the federal agency may need to postpone the deadline set forth in order to better develop the “standards and infrastructure” necessary for advancinghealth information exchange. Essentially, AHA proposes that CMS wait until it has more experience with the challenges and achievements under Stage 2 MeaningfulUse requirements before moving forward with finalizing the mandates for Stage 3 Meaningful Use.

The AHA Executive Vice President Rick Pollack does support that the Stage 3 Meaningful Use proposed rule expands on health information exchange and patient engagement, but reminds CMS that this year is the first time many providers across the country have implemented Stage 2 Meaningful Use requirements and preparing for a deadline in 2018 will prove difficult.

Currently, there are extensive challenges in attesting to Stage 2 Meaningful Use requirements, Pollack explains in the letter to CMS. Some of the issues to overcome include “lack of vendor readiness, mandates to use untested standards, insufficient infrastructure to meet requirements to share information and compressed timelines.”

Additionally, healthcare providers have found that EHR implementation and upgrades toward improvedinteroperability as well as ICD-10 coding proves to be extraordinarily expensive. AHA discovered that, between 2010 and 2013, US hospitals as a whole spent $47 billion annually to adopt health IT platforms. AHA also mentioned how helpful it is that CMS changed the EHR reporting period between 2015 to 2017 to better address some of these challenges.

Nonetheless, the proposed modifications to Stage 2 Meaningful Use requirements in the middle of its lifecycle only illustrate how various issues need to be addressed before a ruling is finalized and an approaching deadline passes only to find providers unprepared.

“Hospitals strongly support the long-term goal of the EHR incentive programs, and they have been working diligently to implement new health information technology to improve the quality and coordination of care for patients,” Pollack wrote in the letter to CMS. “While the Stage 3 proposals offer promising ideas that could further health information exchange and support greater patient engagement, we do not yet have sufficient experience at Stage 2 to be confident that the proposals for Stage 3 are feasible and appropriate. In addition, the standards and information exchange structures needed to support many of the Stage 3 requirements are not yet mature enough to be included in regulation. Furthermore, Stage 3 proposals such as relying on third-party applications to access sensitive patient data in EHRs may be a successful mechanism for the exchange of patient data information, but they raise important questions about patient privacy and information security that must be carefully considered.”

Thinking about switching EHRs? This is a really big decision. Much bigger than choosing between the red patent pumps and snakeskin peep-toes, or your salsa selection at Chipotle. So before you rush into making a move, consider the following:

Why am I even considering switching in the first place?Is the vendor sunsetting your product or not keeping up with ONC (Office of National Coordinator) certification?Or does your staff report that it is no good (probably using much stronger language), that there are too many clicks, or can’t get desired reports?

Analyze your needsMap your workflow. Carefully consider WHY each step occurs – is there a clinical or regulatory reason? If not, get rid of it. Taking bad processes into a new system will not make you any happier with the new technology than the old. Sometimes an outside set of eyes can help shed light on these waste points. There is a pretty forest out there if you stop looking at the beetle-infested trees. You may not even need the following steps if you can improve how you use your current system.

Assess your infrastructure and securityAlong with mapping processes, you should also have an inventory and map of hardware and networks. Assuming you are maintaining an up-to-date security risk assessment, this may be a good place to start.

Do your researchI know, many of us do not want to re-live college research projects without the reward of more letters after our name, but you will not regret this. Resources include the ONC, HIT.gov, and KLAS. You may also consider a consultant who is familiar with many EHRs and regulations.

Make a comprehensive list of your needs and shopA key step that is often not given enough attention is to delineate your requirements in complete detail. These requirements can then be used to create a Request for Information (RFI) or Request for Proposal (RFP) to any potential software vendor. There are hundreds of products out there and they all may dazzle you with a demo. Get under the hood and test drive when possible. Seek out as many organizations that you can who use the product for a balanced opinion.

The price tag is not always straightforwardSure, the monthly subscription, setup fees, yearly fees, may be clearly spelled out in the contract, but what about internal costs or future upgrades? Ask the vendor about their upgrades and additional modules processes, as these items will be inevitable with changes in technology and regulation. Are these generally associated with additional fees? Will your current hardware be sufficient or do you need to purchase new? Costs of servers, tablets, and wireless networks should be factored in to your overall cost. What about training for staff or additional IT resources to manage the application? And, as with everything, cheaper is not always the way to go. It may save you a few dollars now but the long range price may be high.

Due diligence complete. I am ready to switchRead your contract carefully. Make sure you know your level of support as to the hours, turnaround time, and go-live. Make sure they were clear with an implementation schedule and assumptions.Server, web, yearly/monthly fees

They can just move all my current patient information into the new system, right?Um, not so much. Data mapping and migration is difficult, time consuming and costly.There is no 1 to 1 map from any system to each other. If you choose to migrate data, consider only active patients with a critical subset of their information, such as medications, problems, diagnoses, etc. Another alternative is a data archiving service where you can have access to view your data at any time.

Many perfectly good EHRs have failed due to bad implementationsThe vendor will have a project manager and an implementation plan. However, you need to have both of your own as they will not account for every aspect of your workflow and organizational needs. If you have not implemented a technology solution before, it is highly suggested you get help from an experienced implementation specialist or project manager. Planning and detailed checklists should be a critical part of your implementation. During the design and build process try to customize as little as possible. It will take several months to know what the system can do and is best optimized at a later date. You can also not have too much training or at-the-elbow support for weeks after go-live. These are often the highest complaints heard.

Now, given all that, is it still feeling hot in the kitchen or are you using your frying pan for the best meal you have ever had?

Should you implement an EMR or an EHR? Do you know the difference? Is there a difference?

In theory, and by definition, there is a difference and it should play into any provider’s clinical software selection. At the same time, marketing messages and technical terminology have clouded provider’s understanding of the two software definitions.

EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.

EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.

By these definitions, an EHR is an EMR with interoperability (i.e. integration to other providers’ systems). More on this later…

Who Needs Which?

Marc Anderson, CEO of the AC Group, says it comes down to the words “medical” and “health.”

An EHR will provide a more comprehensive view into a patient’s health and history by pulling information from other systems, providing clinical decision support and alerting providers to health maintenance requirements. It will help providers report and measure quality indicators for pay-for-performance incentives.

Meanwhile, an EMR is a more silo’d record of a single diagnosis or treatment, most likely used by a specialist. If your responsibility is taking care of one unique problem – perhaps an orthopedist setting a bone – then a stand-alone EMR may well be sufficient. Certain specialists may not need information about patient history as much as they need specialty-specific workflows and templates.

The College of Healthcare Information Management Executives (CHIME) released their comments to CMS about the proposed rulings on May 27. CHIME representatives found that Stage 3 Meaningful Use requirements under the proposed rule are “too ambitious” and need some significant revisions, according to a company press release.

Additionally, the organization showed complete support of CMS in reducing the EHR reporting period in 2015 from a full year to a continuous 90-day period. CMS did reduce the number of objectives under the Stage 3 Meaningful Use proposed rule and improved the reporting periods, but the high number of total proposals for the Stage 3 portion was thought “unworkable” by CHIME representatives.

“Were all requirements finalized as proposed, we doubt many providers could participate in 2018 successfully,” CHIME stated in its public comments. “And with so few providers having demonstrated Stage 2 capabilities, we question the underlying feasibility of many requirements and question the logic of building on deficient measures.”

There are specific steps CHIME offered that may

improve attestation to Stage 3 Meaningful Use requirements if CMS integrates the suggestions in the final ruling. These steps are:

1) Requiring a 90-day reporting period under Stage 3 Meaningful Use regulations for the first year of attestation

2) Retain the same 90-day period for any eligible healthcare provider participating in the Medicare or Medicaid EHR Incentive Program for the first time

6) Give providers a 90-day remission in any calendar year for program upgrades, bug fixes, or EHR optimization

CHIME was especially concerned with “unrealistic” health information exchange measures and the ongoing uncertainties around patient action objectives. CMS proposed that modified Stage 2 Meaningful Use requirements would mandate that only one patient among a provider’s consumer base would need to view, download, and transmit their health data. However, under the Stage 3 Meaningful Use proposed rule, this requirement goes up to 25 percent of the patient population among eligible hospitals and professionals. CHIME was also concerned that attesting to Stage 3 by 2018 was too soon and providers would not be ready.

“While we acknowledge policymakers’ intention to make each Stage more difficult than the last, we are concerned with the strategy that envisions Stage 3 serving as both the apex of MU requirements and as a starting point for those providers with no experience at Stage 1 or Stage 2 of the EHR Incentive program,” CHIME said. “We worry some of the objectives pose too great a stretch for seasoned meaningful users, let alone those who have never participated in the program.”

Amazing Charts just announced a new EHR partner program. This isn’t something that’s particularly new for EHR vendors. They all have lots of partners. Some have formalized them into a program like athenahealth has done with their More Disruption Please (MDP) program. Others are much more quiet about the partners they work with and how they work with them.

What’s clear to me in the EHR industry is that an EHR vendor won’t be able to do everything. There are some that like to try (See Epic), but even the largest EHR vendor isn’t going to be able to provide all the services that are needed by a healthcare organization. This is true for ambulatory and hospitals.

Since an EHR vendor won’t be able to do everything, it makes a lot of sense for an EHR vendor to have some sort of partners program. The challenge for an EHR vendor is that a partner program comes with two major expectations. First, the partner has a high quality integration with the EHR software. Second, that the partner is something that the EHR vendor has vetted.

The first challenge is mostly a challenge because most EHR vendors aren’t great at integrating with outside companies. This is a major culture shift for many EHR vendors and it will take time for them to get up to speed on these types of integrations. Plus, these integrations do take some time and investment on the part of the EHR vendor. When there’s time and investment involved, the EHR vendor starts to be much more selective about which companies they want to be working with long term. They don’t want to spend their time and money integrating with a company which none of its users will actually use.

The second challenge is that EHR users assume that an EHR partner is one that’s been vetted by the EHR vendor. Even if the EHR vendor puts all sorts of disclaimers on their partner page, the EHR vendor is still associated with their partners. The written disclaimers might help you avoid legal issues, but working with shady partners can do a lot of damage to your reputation and credibility in the marketplace. I actually think this is probably the biggest reason that EHR vendors have been reluctant to implement partner programs.

I think over time we’ll see the first problem solved as EHR vendors work to standardize their APIs for partner companies. As those APIs become more mature, we’ll see much deeper EHR integrations and the costs to an EHR vendor will drop dramatically when it comes to new partner integrations.

The second problem is much harder to solve. My best suggestion for EHR vendors is to create a platform which allows your users to help you vet potential partners. Not only can they participate in the vetting process, but it can also help you know which partners would be useful to your users. Is there anything more valuable than user driven partnerships? It also puts you in a good position with potential partners if you already have users interested in the integration.

However, an EHR vendor shouldn’t just leave potential partnership requests to their users. Many of their users don’t know of all the potential partner companies. Users are so busy dealing with their day jobs that they often don’t know of all the potential companies that could benefit their practice or hospital. Certainly you should accept user input on potential partnerships, but an EHR vendor should also seed the potential partner feedback platform with a list of potential partners as well. The mix of an EHR vendor created list together with user generated partner lists is much more powerful than one or the other.

We’re just at the beginning of companies partnering and integrating with EHR vendors. I expect that over the next 5 years an EHR vendor will be defined as much by the organizations it chooses to partner with as the features and functions it chooses to develop itself.

Increasingly hospitals are recognizing the value of interoperabilitybetween electronic health records and automated dispensing cabinets, or ADCs. In addition to eliminating redundancies during the medication ordering process, linking them helps to reduce medication errors at the point-of-care.

Hackensack University Medical Center recently unveiled this interoperability between its ADC from Omnicell and its Epic EHR.

Now nurses are able to easily interface with the complete medication management system within one application at the patient's bedside, said Nilesh Desai, director of pharmacy at HackensackUMC.

"With the addition of the interoperability piece, it is now embedded directly into Epic and as you open a patient's chart, automatically you can launch and schedule the medications and view if the medication has been delivered by pharmacy or not," said Desai.

With this interoperability, he said, that there's not a separate login and the nurse doesn't have to remember another password: It's connected to the EHR and it directly opens up to the patient's chart.

Normally when there is a medication that has to be delivered from the pharmacy, the nurse has to go back to the cabinet or look into the cabinet to see if pharmacy delivered it or not.

"If the medication is not delivered the medication is grayed out and the nurse will be unable to remove it," said Desai. "As soon as a pharmacy technician delivers a medication, it lights up. As a nurse, you don't have to go to the cabinet to find out if the medication has been delivered. A nurse can do it directly from a computer from anywhere in the nursing unit. It saves quite a few steps and time."

Shafiq Rab, MD, vice president and chief information officer at HackensackUMC, points out that there are other benefits of interoperability between EHRs and ADCs. One is that while the drug is being procured from the pharmacy system, it also checks for allergies, drug-to-drug interaction, and drug-to-food interaction.

Clinical inefficiencies raise red flag for hospitals

A benefit analysis extrapolated from a 2013 white paper prepared by Cerner, "The Clinical Benefits of CareAware Enhanced Dispensing," revealed that prior to interoperability between EHRs and ADCs, nurses at Penn State Milton Hershey Medical Center were spending on average of 8.5 minutes on a single patient's medication pass resulting in clinical inefficiencies within the medication administration and reconciliation process. Post-implementation they spend on average 5.8 minutes, a 32 percent improvement.

According to the white paper, CareAware "allows clinical information to be shared seamlessly between the two systems improving workflow and patient safety," while allowing the nurse to view the same information in both systems.

Flip Groves, vice president of business development in the Medication Management Solutions Group at CareFusion/Pyxis, said such interoperability extends not only to the EHRs, but also into the entire, end-to-end, medication-management process.

He added that interoperability also enhances patient safety and clinical workflow by eliminating opportunities to introduce errors, and by providing the users with the right information, through the right application, in the right place, at the right time.

Dan Pettus, vice president for IT in the Medication Management Solutions group at CareFusion/Pyxis, said that interoperability is significant not only for EHRs and ADCs but also for other devices including IV pumps and ventilators.

That capability, said Pettus, is the tie-in to all of the necessary connections that you need to make these applications from products interoperable.

"It's beneficial to our customers to have one-stop shopping when it comes to those technology platforms," said Pettus. "Less interfaces, less complexity, it reduces to maintain these things over time."

Point-of-care medication errors averted

Mark Neuenschwander says that for years he has tried to draw attention to the gap between the point-of-dispensing and the point of administering medications.

"It is possible for nurses to get the right medications for the right patients at dispensing cabinets and then to administer them to the wrong patients," said Neuenschwander, a Bellevue, Wash.-based consultant on bar code-enabled medication dispensing, preparation and administration.

Bar code medication administration, Neuenschwander says, has matured and become commonplace in today's hospitals to verify patients and medications to address this problem, but be noted that in addition to verification, a sound medication use process requires information.

"In addition to verifying that they have the correct medications for a particular patient, they also need to have access to information about medications both when they come from dispensing cabinets and when they are at the point-of-care."

Neuenschwander, cofounder of the unSUMMIT for Bedside Barcoding, asserted that nurses must document what is administered and that this must occur at the point of care, not at the point of dispensing.

"It is critical that what the nurse sees at any point is up to date. I am thrilled with the ongoing efforts and success in integration information with information systems, dispensing cabinets, and point of care technologies," he said.

This article summarizes the link between medication dispensing cabinets and EMR. The current systems in place require bar code scanning of the patient and the medication to ensure the right drug is going to the right patient. New technology will also allow the nurse to view if the medication is available at the dispensing cabinet from any computer on the unit. This would definitely be a time saving improvement. Currently, I sometimes will walk back and forth numerous times to the dispensing cabinet to see if my drug has arrived yet. With this new innovation, I could avoid this and use my time more effectively.

The volume of telemedicine visits is growing at a staggering pace, and they seem to have nowhere to go but up. In fact, a study released by Deloitte last August predicted that there would be 75 million virtual visits in 2014 and that there was room for 300 million visits a year going forward.

These telemedicine visits are generating a flood of medical data, some in familiar text formats and some in voice and video form. But since the entire encounter takes place outside of any EMR environment, huge volumes of such data are being left on the table.

Given the growing importance of telemedicine, the time has come for telemedicine providers to begin integrating virtual visit results into EMRs. This might involve adopting specialized EMRs designed to capture video and voice, or EMR vendors might go with the times and develop ways of categorizing and integrating the full spectrum of telemedical contacts.

And as virtual visit data becomes increasingly important, providers and health plans will begin to demand that they get copies of telemedical encounter data. It may not be clear yet how a provider or payer can effectively leverage video or voice content, which they’ve never had to do before, but if enough care is taking place in virtual environments they’ll have to figure out how to do so.

Ultimately, both enterprise and ambulatory EMRs will include technology allowing providers to search video, voice and text records from virtual consults. These newest-gen EMRs may include software which can identify critical words spoken during a telemedical visit, such as “pain,” or “chest” which could be correlated with specific conditions.

It may be years before data gathered during virtual visits will stand on equal footing with traditional text-based EMR data and digital laboratory results. As things stand today, telemedicine consults are used as a cheaper form of urgent care, and like an urgent care visit, the results are not usually considered a critical part of the patient’s long-term history.

But the more time patients spend getting their treatment from digital doctors on a screen, the more important the mass of medical data generated becomes. Now is the time to develop data structures and tools allowing clinicians and facilities to mine virtual visit data. We’re entering a new era of medicine, one in which patients get better even when they can’t make it to a doctor’s office, so it’s critical that we develop the tools to learn from such encounters.

It seems pretty obvious: You do the work, you get paid. But unfortunately for many in the healthcare business, it’s not always that black and white.

There are so many obstacles to proper payment, including: complex and confusing billing systems; patients unable to pay their office copay, co-insurance, or deductibles; high outstanding accounts receivable; improper coding vs. documentation; etc. All this and more can lead to outstanding bills and ultimately low cash flow for the practice.

Here are some tips to make sure your practice gets the compensation it deserves:

The Right Code: ICD-10

With the new ICD-10 rules taking effect Oct. 1, it’s imperative that your practice management software and EHR are up to date and that the billers in your practice are trained and ready to go. Improper documentation at some point in the chain of work can lead to a deficit in your bottom line. Make sure that your software is ICD-10-ready.

Ignorance Is Not Bliss: Pay Attention to the Details

Doctors, office managers, and certain staff should be able to access at-a-glance details and have the ability to generate reports if they are employing an efficient billing system. Every doctor should be able to easily access the following data:

• Average daily and monthly revenue categorized by HCPCs and insurance

• Number of outstanding accounts receivable

• Cash value of outstanding accounts receivable

• Number of audits paid/failed status

• Payment and claim status

• Outstanding revenue by HCPCs and insurance

• Monthly adjustment reports

If you are a doctor in a private practice and can’t access this critical information, then at a minimum, you should require a weekly billing report from billing staff or your outsourced billing service. This weekly report should cover the items listed above and will allow you great insight into the "health" of your practice.

Verify Patients’ Benefits Before Their Visit

At the very least, verify patient's benefits before they leave your office. It sounds fairly obvious, but many practices don’t get the patients’ copay before they see the doctor. This could be rectified as easily as keeping patients’ credit cards on file, so it can be the default if the patient fails to bring cash to their visit. Better yet, utilize a practice management system that seamlessly updates you with this information so that you can easily charge in the office. You’d be surprised how something so simple can increase practice cash flow.

Claim Denied? Don’t Let It Go

Make sure your billing staff is diligent about following up on denied claims. Making sure your billing staff or billing service has the right codes can significantly improve this denial rate, but when it does happen, don’t let it go. There should always be follow up on denied claims, but ideally, your billing staff or service should try to catch coding errors before they’re made. Catching coding errors is often better handled by a sophisticated, outsourced billing service — just make sure it offers a transparent view into billing success.

Last month, the Centers for Medicare & Medicaid Services (CMS) released a new proposed rule with several key modifications to meaningful use requirements under the Medicare and Medicaid EHR Incentive Programs. The general public has until June 15 to submit comments to this particular proposed ruling.

The changes are meant to modify the EHR reporting periods from 2015 to 2017. The new reporting period was transitioned to a 90-day period that would line up with the calendar year. Additionally, patient engagement measures under the Stage 2 Meaningful Use requirements were changed.

If the ruling is passed, no longer will providers have to ensure that 5 percent of their patients download, view, and transmit their health information over the next couple of years. According to the proposed rule, only one patient will need to utilize a portal to view, download, or share their medical data.

The American Medical Association (AMA) recently announced their support of the proposed modifications to the meaningful use requirements. In a press release, the AMA stated their prior advocating of offering more flexibility under the EHR Incentive Programs so that providers and healthcare professionals may adopt and utilize health IT systems in a way that benefits their practice and workflow.

“Physicians want to use new technologies that help strengthen physician-patient relationships, improve health outcomes and make them more efficient,” AMA President-elect Steven J. Stack, MD, said in a public statement. “About 80 percent of physicians have already incorporated electronic health records (EHRs) into their practices, but they have faced significant barriers in participating in the Meaningful Use program and many are receiving penalties despite their investments in EHRs. We believe CMS’ proposal offers common sense solutions that, if finalized quickly, will help more physicians use EHRs in a truly meaningful way while supporting patient engagement.”

Within the letter sent to CMS for public comment, the AMA offered additional advice to the organization that could improve attestation to meaningful use requirements. The suggestions revolve around quality measure reporting and removing the overall “pass-fail structure” so that physicians and hospitals that attempted to meet meaningful use requirements and show positive results are not penalized.

Stack continued by discussing the importance of providing patients with secure messaging tools and patient portals and encouraging their consumers to utilize these platforms. At the same time, Stack mentioned that different physicians and healthcare providers have varying circumstances that may impact their ability to have a high percentage of patients viewing their medical information electronically.

For example, providers serving the elderly population or Medicaid-based patients in underserved areas may not have the key demographic that utilizes the Internet, smartphones, or even computers.

The AMA includes guidelines on its website for physicians looking to better engage their patients in their healthcare and the use of the patient portal. The organization is looking to work with physician groups to further patient education regarding accessing health information digitally.

Through these proposed modifications to the meaningful use requirements, CMS will be able to give providers the flexibility needed to successfully attest to the objectives and bring the healthcare industry into the 21st century.

When it comes to the practice of medicine and drug discovery, the federal government plays a role in supporting these sectors and developing legislation that opens up avenues for healthcare professionals and scientific researchers. The House Committee on Energy and Commerce has gone forward with creating legislation called 21st Century Cures that delves directly into stimulating the discovery and development of new treatments and medications for patients across the nation. The legislation also impacts the expansion of EHR interoperability.

While the intentions of the 21st Century Cures legislation is beneficial for drug discovery, the American Hospital Association (AHA) finds that the enforcement strategies under the proposed rules could have negative consequences for providers, particularly in its aim to expand EHR interoperability.

AHA Executive Vice President Rick Pollack stated in a letter to the House Committee on Energy and Commerce that, which the organization appreciates the inclusion of EHR interoperability expansion, the “enforcement mechanisms” could lead to issues for healthcare providers such as putting together an ecosystem in which doctors may be significantly penalized for minor errors.

AHA does support health information exchange and EHR interoperability in pursuit of improving patient outcomes and incorporating new models of care. Nonetheless, AHA finds some issues with the enforcement related to vendors participating in information blocking problematic.

“The bill includes a number of enforcement mechanisms against those who engage in information blocking,” wrote AHA Executive Vice President Rick Pollack in the letter. “On the provider side, we believe that the use of Medicare fraud and abuse mechanisms, such as investigations by the Office of the Inspector General, imposition of civil monetary penalties or exclusion from the Medicare program, is unnecessary and inappropriate to address the concerns that the legislation seeks to remedy. We recommend that you use the existing structures of the meaningful use program to promote information sharing.”

On behalf of AHA, Pollack mentions that the organization appreciates the committee’s aim to ensure EHR vendors are responsible for creating interoperable health IT products. However, Pollack also stated that the committee should instruct the Federal Trade Commission to analyze any anti-competitive behavior among EHR vendors. In particular, Pollack finds the decertification of EHR systems among vendors that participated in information blocking objectionable, as it would affect healthcare providers and disrupt patient care.

“The language also includes decertification as a sanction for vendors that engage in information blocking. Decertification would be disruptive to hospitals and physicians that have invested in and deployed an EHR that is later decertified,” Pollack explained. “However, the inclusion of provider protections against meaningful use penalties if their EHR is decertified makes it more reasonable.”

The protections against payment penalties under the Medicare and Medicaid EHR Incentive Programs would last for more than one year, which would give providers ample time to find a new vendor, develop a suitable contract, install another EHR system, and attest to relevant meaningful use requirements.

Additionally, AHA would like the definition of information blocking to become narrower in order to avoid charges of fraud to be dealt due to standard business practices. Essentially, AHA would like to reduce some of the punitive approaches the committee set forth and develop more positive approaches to expanding health information exchange.

Thanks to some technology incentives from the government over the past several years, electronic health records (EHRs) have permeated the U.S. healthcare industry very quickly. Fewer than two out of 10 physicians used EHR systems in 2001. Just a decade later that jumped to six out of 10. Studies and surveys vary, but most find 75 to 80 percent of physicians are using them today. And, although there are varying opinions, most of the studies I’ve read find EHRs to be useful and beneficial to patient safety and care quality.

However, EHRs are not, by design, communication tools. They’re a treasure trove of information, but they’re rooted in documentation and not purpose-built for workflow communication.

I see the EHR as the documentation or tracking system, and complementary communication tools as how the interactions are actually accomplished. For example, if you’re in IT, your documentation system may be your project management or agile development software. But when it comes down to actually communicating with your colleagues to execute the work on these outlined projects, you connect with them via communication tools like instant messaging, email, or web conferencing.

The EHR is similar in that it is the center of information, but it needs to be complemented by communication tools to manage the minute-to-minute, or even second-to-second, aspects of care delivery. Let’s say a physician wants to order a series of labs. She enters them into the CPOE. Communication occurs so the desired samples are taken from the patient. Tests are run on the samples, and the results are entered into the EHR, right back where they’re supposed to be. Yet, the results still need to be communicated. And it can take a lot of time for phone tag, pages, and so on to finally close the loop on this workflow. Information needs to be communicated quickly to the right people for the most optimized workflows. Technology can move this asynchronous communication to effortless electronic alerts and messaging.

The ICD-10 implementation date is just four short months away. Physicians must ensure that their forms, including their superbills, are ready for the conversion on Oct. 1, 2015.

Superbill Revision

Many physician practices use a superbill to account for the services rendered (CPT codes) and patients' diagnoses (ICD-9 and ICD-10 codes). These forms must be updated on a regular basis to reflect any code changes. The conversion to ICD-10 will require a major overhaul of the superbill. Each ICD-9 code that is listed on the existing superbill will need to be converted to the related ICD-10 code. There is not always a 1:1 match when translating an ICD-9 code to an ICD-10 code. In fact, due to the greater specificity in most areas of ICD-10, there could be several ICD-10 codes that map back to just one ICD-9 code.

CMS' website provides a list of the mappings of ICD-9 to ICD-10 codes called the General Equivalence Mappings (GEMs); view it here: bit.ly/CMS-GEMs. This tool is helpful as a first step for practices to compare the commonly used ICD-9 codes to the related ICD-10 codes. However, the user must keep in mind that these GEMs are not a crosswalk. The full list of ICD-10 codes, including coding guidelines and conventions, must be reviewed to determine the appropriate code assignment.

Since the list of ICD-10 diagnosis codes a practice utilizes could be quite extensive, the use of a superbill for diagnosis coding might need to be reevaluated. There are other solutions, such as the use of EHR, which would better assist physicians in selecting appropriate codes.

It's also important to remember that the physician documentation within the record (outside of the superbill), must justify the services provided and fully describe the patient's diagnoses. The superbill does not stand on its own for coding and billing purposes.

Other Forms Revision

Besides the superbill, there may be other forms that will need to be revised in anticipation of ICD-10. Physician practices should take an inventory of all forms currently used, whether paper or electronic, and review them for ICD-9 codes. Any forms that currently include ICD-9 codes will need to be refreshed with ICD-10 codes.

Some areas that may currently include ICD-9 codes are patient scheduling and registration, documentation templates within the EHR, coding and billing forms, and external reporting/databases. Once these impacted areas are identified, it's essential to communicate any required changes to the forms with the affected parties to ensure readiness for the ICD-10 conversion.

EHR Readiness

Most physicians use some type of EHR within their practice. It is essential that the EHR is ready for the conversion to ICD-10. If the practice has purchased an EHR from a vendor, a readiness assessment should have already been completed several months ago for ICD-10. However, if this process has not been done, practices should contact their EHR vendor immediately to ensure that it will be compliant with ICD-10 on Oct. 1, 2015.

Some practices have created their own "home-grown" EHR which will also need to be evaluated for ICD-10 readiness. Physicians and their coding staff should practice assigning ICD-10 codes within their EHR system to ensure that the system is capable of accepting these codes. It's important to remember that the current ICD-9 codes are between three digits and five digits, whereas the ICD-10 codes are between three characters and seven characters.

Many EHRs have built-in documentation templates that physicians use to assist with capturing the complete clinical picture of the patient. These templates may need to be revised for ICD-10 as well.

Next Steps

Leading up to ICD-10 implementation, a physician practice should have already created an ICD-10 communication plan, developed a budget, completed staff and physician education, performed readiness testing, analyzed documentation, reviewed quality reporting requirements, and revised superbills and other forms. Use these remaining four months wisely to ensure a smooth transition on Oct. 1, 2015.

Both medical device and EHR interoperability is emerging as a key concept throughout the healthcare IT field. More providers and vendors than ever before are making connectivity a priority in the coming years. Whether it’s diagnostics, remote monitoring, physician workflows, or wellness and prevention, EHR interoperability holds true value in enabling these processes, reducing medical errors, and improving the quality of healthcare services across the spectrum.

The market research firm Frost & Sullivan recently published a new analysis report calledHealthcare and Medical Device Connectivity and Interoperability that discusses how health IT infrastructure and connectivity is not identical around the globe. The analysts specifically mentioned how the lack of a health IT strategy could be impairing EHR and medical device interoperability in various countries.

The results in the report show that more than 50 percent of medical providers have not developed an effective healthcare IT roadmap.

While many do realize the importance of computerizing patient records, there is still little progress being made worldwide in improving EHR connectivity based on the findings in the Frost & Sullivan analysis.

Additionally, the lack of interoperability developed among EHR and health IT systems among vendors and manufacturers poses a problem for healthcare providers who attempt to improve medical device and EHR connectivity.

In the United States, future regulations like Stage 3 Meaningful Use requirements will necessitate the need for greater health information exchange and EHR interoperability, which is why vendors and manufacturers will need to develop stronger partnerships in pursuit of effective medical data exchange.

Frost & Sullivan Healthcare Senior Research Analyst Shruthi Parakkal spoke withEHRIntelligence.com and offered more background on the analysis of EHR interoperability. Parakkal discussed some of the most important standards that may aid in improving connectivity throughout the medical sector.

“There has been so much advancement in interoperability standards,” she said. “DICOM [Digital Imaging and Communications in Medicine] standard for imaging and HL7 are currently the most adopted interoperability standards to improve connectivity.”

“In the US, standards are being developed through Direct Project under the Department of Health and Human Services (HHS) and the National Coordinator for Health IT,” Parakkal explained. “Certain initiatives are established under Direct Project, which has about 200 members. The group has established a framework for sharing healthcare information that will help providers to qualify for meeting Stage 1 Meaningful Use requirements.”

“The ICD-10 transition is very critical since it is otherwise difficult to classify medical information electronically,” Parakkal mentioned.

When asked what the most interesting finding was discovered in the Frost & Sullivan analysis on EHR interoperability, Parakkal mentioned the lack of a healthcare IT roadmap among about half of medical providers.

“An interesting fact uncovered relates to the need for interoperability standards,” stated Parakkal. “Providers and vendors need to utilize existing standards more and develop a health IT roadmap. Additionally, it is beneficial to get device manufacturers, health IT professionals, nurses, and other medical staff involved in promoting interoperability.”

“One other interesting factor that benefits interoperability is the advances in Wi-Fi, Bluetooth and RFID technology that provides essential connectivity in the medical field,” she included.

When asked how healthcare providers should go about developing a healthcare IT roadmap and working toward greater medical data exchange, Parakkal explained, “Most healthcare providers have a variety of medical devices, but are finding it challenging to integrate new systems with legacy infrastructure and increase connectivity. The high costs and abundance of workflows also pose connectivity challenges to the hospitals.”

To solve these issues, providers need to “look to vendors who offer medical device connectivity solutions. Both partnering with medical device connectivity vendors and interfacing with middle ware/API vendors can help. Also, it is important to train the staff on ways to utilize new systems. Additionally, it is beneficial to have all devices integrated to the EHR,” Parakkal articulated.

Additionally, the Frost & Sullivan analyst answered an inquiry about how vendors and providers can prevent information blocking and support the development of interoperable products.

“There is a lot of change happening in the market and new solutions for integrating devices,” she mentioned. “Many manufacturers have begun sharing medical information as opposed to proprietary gateway solutions. Establishing alliances among health IT vendors is useful. .”

Continua Health Alliance is one such alliance that promotes information sharing. Partnering with vendor-neutral groups, especially in the mHealth field, can prove beneficial to stopping information blocking,” Parakkal concluded.

Once the HITECH Act was passed in 2009, EHR adoption and implementation of health IT systems grew tremendously over the coming years, as more providers began focusing on obtaining financial incentives from the Centers for Medicare & Medicaid Services (CMS) under the EHR Incentive Programs. While patient safety and quality of care has improved with the integration of computerized records, EHR adoption challenges have led to certain burdens among healthcare professionals.

From the potential for medical errors to a conceivably negative impact on the patient-doctor relationship, EHR adoption challenges will need to be addressed as healthcare facilities continue to implement computerized systems in order to qualify for the Medicare and Medicaid EHR Incentive Programs.

Fourteen experts from a wide background of organizations including Kaiser Permanente, Cerner Corporation, and Nextgen Healthcare put together a report to illustrate the future of EHR technology and how to overcome many common EHR adoption challenges. The report was published on behalf of the American Medical Informatics Association EHR 2020 Task Force.

Some of the “unintended clinical consequences” of EHR implementation has been the longer work hours required from the data entry around computerized patient records and less time for physicians to communicate directly with their patients. Additionally, EHR interoperability has not grown across the medical sector as quickly as previously hoped. Health data exchange is lacking due to information blocking among providers and vendors alike.

The overall goal of the health IT industry is to develop an effective and interoperable health information exchange platform in which patients, providers, healthcare professionals, and public health agencies have ready access to key data. However, EHR adoption challenges have put up roadblocks toward meeting this goal.

The Task Force offers ten suggestions for improving on health IT systems and overcoming some common EHR adoption challenges. First, it is important to decrease the overall burden from a high amount of data entry on the physician. When it comes to diagnosis and treatment, the process of capturing data has fallen on the physician, but moving the data entry toward other members of the healthcare team or even patients themselves could prove beneficial.

“Clinicians remain uncertain regarding who can and cannot enter data into the record, placing a tremendous data entry burden on providers, the most expensive members of the care team,” the Task Force wrote in the report. “Clinician time is better spent diagnosing and treating the patient rather than charting. Regulatory guidance that stipulates that data may be populated by others on the care team including patients would reduce this burden.”

Another suggestion the Task Force offered is to include sound recording during a patient visit instead of manually entering information into the EHR system. When it comes to discussing medical history, conducting a basic physical exam, and giving patients advice, doctors would benefit from a sound recording instead of pure data entry.

By following the suggestions offered in the Task Force’s report, the healthcare sector should move forward in properly addressing some common EHR adoption challenges and paving the road toward a future of effective and interoperable health IT products.

The economics of flash storage are changing, and the healthcare industry is in a perfect position to take advantage of these changes to solve multiple challenges.

Healthcare has an exploding data storage problem. Increased use of electronic health records (EHRs) and digital images (among other issues) has healthcare CIOs struggling for cost-effective storage solutions, including the cloud and aggressive data-tiering.

The issue with these solutions is that the Health Insurance Portability and Accountability Act (HIPAA) is very specific and rigorous about putting data in the cloud. Choosing the wrong partner could expose you to risk and fines. And, surprisingly, with the exception of “cold” data — which is usually held on tape and other cheap storage solutions — flash storage is starting to be more economically viable for tier 1 storage, and possibly for lower tiers as well.

It isn’t just that flash storage is getting cheaper (though it is). It’s also that flash storage lets you save money on the surrounding infrastructure. On a pure GB/dollar point of view, spinning disks are still cheaper than flash storage, but that’s not the right way to look at it anymore.

Flash storage lowers your storage footprint by 84 percent, saving you money both in terms of physical space and environmental costs. Because of its 90 percent lower latency, flash allows you to run more virtual machines and fewer physical servers, further reducing costs. Flash storage also allows better storage utilization and better scalability.

And perhaps the most overlooked part of all of this is that, because of all the savings above, you often lower licensing costs because you are running less hardware. Add it all up, and the case for flash improves significantly.

Benefits of using flash storage in healthcare

The obvious first benefit of using flash storage in healthcare is that it gives you the opportunity to make more data readily available with low latency and at lower costs than other solutions. This is not merely a matter of convenience, it is an actual necessity in healthcare.

Reforms around the Affordable Care Act put more emphasis than ever on preventive care. The emphasis for health professionals is on follow-up care to prevent patient re-hospitalizations and on intervening with chronic diseases before they become acute. In other words, more data will be “hot” and an increasing number of departments within a healthcare organization will be accessing that hot data. Flash is a good way to respond to these changing methods of accessing your data.

Another major benefit to bringing more flash into healthcare is its advantages to virtual desktop infrastructure (VDI). Virtual desktops are an attractive solution in a healthcare environment, and flash’s low latency is ideal for it. VDI allows use of EHRs in a much more secure environment. Terminals throughout the hospital (sometimes left unattended by necessity) are no longer physical points of access to privileged data and sensitive networks. Administrators can manage access and permissions better with VDI, and more easily update terminals. This is especially valuable for remote clinics, where IT professionals are not always available to easily secure and update remote terminals. A secure virtual desktop makes HIPAA violations far less likely.

Another reason flash storage is beneficial for healthcare environments is because it scales fast. Mass casualty and trauma events can tax systems and quickly use up system resources. Flash, with its low latency and ease of use with virtual machines, allows hospitals to spin up storage quickly in response to emergencies.

Future potential for flash storage in healthcare

In the near future, you will also see flash storage used in medical research, as well as in the growing field of personalized medicine. Particularly resource-intensive functions, such as genome mapping, will become more common in both research and personalized medicine. These advances will mean that medicine will be prescribed, in part, based on a patient’s genetic makeup. For instance, some medication has been known to work on some people and blocked in other people with certain inhibiting genes. Previously, this medication would fail to be approved by governing bodies.

However, personalized medicine and big data might soon be giving a new lease on life to these drugs. The data storage needs to accommodate these advances will increase exponentially, and Flash will serve as a major component in meeting the challenge. Now is the time to build your internal capabilities and infrastructure in preparation for the future data storage needs of healthcare.

How much you use flash depends partially on your type of environment. Some healthcare enterprises will be able to use cheaper options for some or all of their storage needs. But the economics of flash are changing. Less hardware, less physical space, less latency, combined with more scalability and power means flash, and even all-flash storage arrays, may be the right solution for a healthcare CIOs needs.

Ever since the HITECH Act was passed and the Medicare and Medicaid EHR Incentive Programs were established, more than $29 billion was put toward expanding EHR implementation and health information exchange. Eligible physicians and hospitals were encouraged to adopt EHR systems and health IT platforms by offering financial incentives to those that do. Additionally, under the EHR Incentive Programs, reimbursement penalties would be given to those that have not met meaningful use requirements by a certain period. Despite the clear pathway toward medical data exchange, various stakeholders have participated in health information blocking, which impedes the goals of the healthcare IT industry for improved access to key data.

The New York Times reported that administration officials have found hospitals and laboratories along with EHR vendors participating in health information blocking in order to keep their consumer base from jumping toward a competing healthcare provider.

The federal government is currently attempting to create an environment across the healthcare industry in which medical information will flow freely from one facility to the next. The Obama Administration continues to make it a priority for hospitals and clinics to adopt EHRs and computerize patient records.

President Obama signed a stimulus bill upon taking office that gives hospitals and doctors incentives for implementing certified EHR technology. While large numbers of healthcare providers have adopted electronic records systems, the problem at hand is that few are able to share patient data across platforms designed by different vendors. Essentially, health information blocking delays the progress of EHR interoperability.

“We have electronic records at our clinic, but the hospital, which I can see from my window, has a separate system from a different vendor,” Dr. Reid B. Blackwelder, chairman of the American Academy of Family Physicians, told the news source. “The two don’t communicate. When I admit patients to the hospital, I have to print out my notes and send a copy to the hospital so they can be incorporated into the hospital’s electronic records.”

Another pediatrician from Massachusetts also lamented that he has tried and failed to connect medical records with a hospital’s EHR system in order to better coordinate care with his patients. Not long ago, the Office of the National Coordinator for Health IT (ONC) sent a report to Congress expressing the need to put an end to health information blocking.

Additionally, the costs of sharing data among medical practices are creating barriers and essentially showing that various providers decline to share key data that is needed to treat a patient regardless of their condition.

Certain companiesare also making it more difficult for hospitals to connect to multiple laboratories and technology services while others have customers sign strict contracts that prohibit them from easily choosing a different EHR platform.

Recently, a House Committee passed a bill that states health information blocking is a federal offense. It is also against the law for doctors and hospitals to deliberately take part in health information blocking if they are receiving federal incentives from the Centers for Medicare & Medicaid Services (CMS) for adopting certified EHR technology, according to a bill passed in Congress last month.

Through federal regulations, it is possible that health information blocking could become a problem of the past.

March 2015 saw the 3rd stage of Meaningful Use incentives come into effect. We take a look at what is included and how it will affect your organization’s efforts to seek these incentives.

As part of the HITECH Act passed by the Obama administration in 2009, electronic health records (EHR) were mandated for health care providers to provide a superior health experience with an electronic records system delivered more efficiently. Eligible providers (EP) are required to meet certification for each EHR stage in order to qualify for Centers of Medicare and Medicaid Services (CMS) Incentive Programs. The last stage of this Act was implemented in March 2015 as the Stage 3 Meaningful Use (MU) portion.

What is Stage 3 Meaningful Use?

Stage 3 Meaningful Use is the final implementation program to ensure that all direct care health providers are utilizing EHRs to effectively improve their delivery of health services. Within this stage there is greater flexibility and simplification for health care providers easing late adopters into HITECH and making those already apart of HITECH the ability to further develop their EHR programs. Requirements to meet the incentives given by the government as part of this program include several specific targets to be met in order to receive the incentives for joining the program.

The purpose of stage 3 is no longer just data capture, EHR adoption or improved information processes but focuses on improved outcomes. 25% of patients must be engaged in secure private messaging with their provider, 25% must be able to view or transmit data from their own records, 60% of lab work requests including imaging must be sent electronically, 80% of drug prescriptions must be sent electronically and lastly 15% of patients must generate health data using applications or health devices. These requirements differ depending on your health care institution’s choices for menu set objectives as opposed to core objectives.

Differences between Stages 1,2,3

Stage 1 focused on data capture and sharing information between the EP and the patient. It focused on ensuring data capture was in a standardized format. Then using that information to track key clinical conditions to enable effective communication for care coordination and using that to engage patients and their families in their care. Stage 2 focused on advanced clinical processes and the exchange of information. This stage dealt mainly with increasing information transfer electronically.

Stage 3 Meaningful Use focuses on taking the benefits from Stage 1 and 2 in order to improve safety, quality, efficiency of processes and information to affect an improved health outcome for patients.

Bottom Line for Your Health Organization

Although there is not a legislated mandatory adoption of EHRs for EPs, there are still consequences. The two most relevant are the loss of sizable incentives for developing your EHR program from the government. These incentives depend on whether you apply under Medicare or Medicaid. If you do not implement EHRs and certify under the MU program, you will lose 1% of the reimbursement under Medicare and Medicaid physician fee schedule covered amount per year to a maximum of 5% after five years.

There was a very bad practice that was started thanks in large part to EHR software implementations. That practice is called documentation by exception and it’s employed by many (most?) EHR vendors. For those not familiar with documentation by exception, here’s a definition:

Charting by exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail.

In the US, we all know why this type of documentation was implemented. By documenting all of the normal finding along with the exceptions, then the doctor is able to bill the insurance company at a higher level. I totally understand why doctors want to bill at a higher level. In fact, it was the argument that most EHR vendors would make when they were selling their product to doctors. The EHR was able to help doctors bill at a higher level and get paid more.

While this is going to be hard to change for this reason, there are so many unintended consequences associated with using documentation by exception in these practices. I know so many doctors that are literally embarrassed to share their chart notes with their colleagues because their chart notes are these long, cumbersome notes that are filled with normal findings that provide no value to anyone. Many of these doctors have resorted to creating a separate “short” note that only has the relevant “exceptions” detailed when they send their chart notes to another doctor.

Every doctor knows what I’m talking about, because they’ve found these long lengthy notes that are totally unusable. Plus, in many ways it puts a doctor at some risk if they documented a long list of “normal” items when in fact they didn’t actually check to see if everything was normal or not. However, more important than this is that the doctor can’t even read their own historical notes because they’re so cluttered with all these “normal” findings that it takes real work and effort (Translation: Wasted physician time) trying to search through these awful notes.

If somehow all of these normal findings that were being documented could add some value down the road, then I might change my mind about documentation by exception. However, I can’t imagine any useful clinical benefit to documenting a bunch of normal findings that weren’t actually checked or that were only casually observed. If you didn’t document something was wrong, then we can assume that everything else was normal or at least the patient didn’t complain of anything else. Why do we need to document it clinically? The answer is we don’t and we shouldn’t (except for the getting paid comments above).

We need to find a way to abolish these documentation by exception notes from healthcare. In the US this will be hard since it’s so tied to the payment system, but I’m sure smart minds can figure out a way to fix it. Every doctors I’ve ever talked to wants this solved. It almost makes the EHR notes useless to document this way. This is one more driver in the US system towards concierge and direct primary care models. In these cases, the doctors aren’t worried about reimbursement and so I can’t imaging they’d even consider documenting a patient visit in such an awful manner.

A part of me wonders if EHR vendors will work to solve this problem as well. They could have the beautiful note and the crappy, mess of a note. They’ll use less vulgar terms like the “clinical note” and the “billing note” or something like that, but maybe that’s a small step in the right direction to satisfying the clinical needs (short, concise, relevant notes) together with meeting the billing requirements note. It’s sad that EHR vendors need to do something like this, but it would be better than the current state of EHR notes.

While certified EHR technology has been considered a surefire way to improve patient safety, there are many examples proving the opposite and finding that these health IT systems may lead to medical errors that threaten patients’ lives.

The majority of medical technologies – whether infusion pumps, cardiac monitoring devices, or certified EHR technology – have warnings that tell physicians when an action is unsafe for the patient. Through these alerts, clinicians are expected to stop a prescription or a medical procedure deemed dangerous for a particular patient. In particular, some important alerts are meant to notify a doctor whether a patient will have an allergy or negative drug reaction.

However, the widespread computerization throughout the clinical setting has brought an enormous number of alerts among different medical devices, which physicians manage every day. A study conducted last year shows that monitoring devices across 66 patient beds in an academic hospital generated at least 2 million alerts throughout a single month.

In another study surrounding ambulatory care, computerized provider order entry (CPOE) systems generated alerts for as much as 6 percent of all orders entered, which means doctors dealt with dozens of warnings per day.

When it comes to managing these large amounts of warnings, many clinicians experience alert fatigue and become desensitized to the safety alerts. This could be a major problem for the healthcare sector, as physicians may ignore some warnings due to alert fatigue and cause serious medical errors within the clinical setting. The results show that many physicians override most CPOE warnings.

With more exposure to these warnings and additional use of health IT systems, physicians become even more prone to alert fatigue. This problem is also due to the mere fact that many of these alerts generated via CPOE systems are often “clinically inconsequential,” AHRQ reports. The problem with ignoring certain alerts that do not pose harm is that clinicians will also bypass any warnings that could lead to a serious safety issue for a patient.

Essentially, alert fatigue and the high number of warnings may be leading to additional medical errors and patient safety issues throughout the healthcare industry. The widespread use of certified EHR technology may not have the intended consequences once hoped for with regard to quality care improvements.

In fact, a Boston Globe investigation from 2011 shows that alert fatigue and the failure to respond to critical warnings via medical devices led to more than 200 fatalities across a five-year period.

AHRQ gave some recommendations to prevent some of the issues associated with alert fatigue. Increasing alert specificity and eliminating inconsequential alerts, customizing alerts to each individual patient, providing tiers for alerts with regard to severity, and using human factors strategies when designing the warning systems may all lead to greater patient safety and a reduction in medical errors associated with alert fatigue.

Over the last two decades, the medical industry has changed drastically in terms of patient care and access to medical records. It was nearly impossible to obtain one’s own health record 20 years ago. Forbes reports that patients had little choice but to press legal action if they wished to access their own medical data.

In 1996, however, the Health Insurance Portability and Accountability Act (HIPAA) was passed, which did offer legal protections to patients who needed to see their health records. Nonetheless, there was still significant difficulty in accessing this information and most people never went through the challenging process.

Today, these problems are slowly disappearing, as patients have more ability to readily view their medical history and test results via patient portals and through other electronic means.

A study published earlier this year shows that after three hospital systems in separate states offered their patients the ability to view their health records and physician notes, nearly 70 percent of patients reported understanding their conditions better and taking better care of themselves including remaining vigilant about taking their medications on time. The results from the study also showed that providing patients with this ability did not majorly impact the physician workflow.

The design and evolution of certified EHR technology and health IT systems that held medical data are now changing toward a more cloud-based and mobile platform. This leads to more digitizing of medical records and providing more flexible solutions for healthcare professionals within the clinical setting.

Both mobile health and wearables are also impacting the design of certified EHR technology. The Apple watch, for instance, could potentially hold relevant medical data for physicians to view and patients to access. Additionally, mobile apps on smartphones or tablets could be used by patients to request drug refills and securely message doctors or nurse practitioners.

In a new report from market research firm IDC, Judy Hanover, Research Director at IDC, explains, “The new concept of flexible, mobile, cloud-based acute care EHR supports digitizing paper workflow and reengineering processes … There’s a huge appetite for getting better workflows into healthcare, looking at department specific and mobile apps. I would see an environment where hospitals and health systems would perhaps rip out and replace in some cases.”

According to the report, it is expected that over the next few years, providers will begin to replace their current certified EHR technology with cloud-based solutions instead. Greater investment will continue to be poured into the health IT industry as providers move onto meeting Stage 3 Meaningful Use requirements under the Medicare and Medicaid EHR Incentive Programs.

Additionally, the future of EHRs will continue to depend on EHR interoperability and the ready access of medical data across the healthcare industry. Forbes states that many within the medical sector believe EHR interoperability will be the “biggest game changer.” However, it may take longer than expected for interoperability and medical data exchange to expand across multiple healthcare settings, as this industry “moves slowly.”

According to the survey, large practices tended to select EHR systems from a limited pool of products, compared with smaller practices.

Specifically:

60% of respondents from practices with 26 or more clinicians reported using one of just 10 different EHR systems; and

51% of respondents from practices with one to three clinicians reported using one of 10 EHR systems.

According to Shari Erickson -- senior vice president of the division of governmental affairs and medical practice of the American College of Physicians, which co-founded AmericanEHR Partners -- the 40% of larger practices that used an EHR system other than the top 10 were spread out among 86 vendors.

Top Vendors

Overall, the two top vendors were:

Epic, with 14% of the market share; and

Allscripts, with 9% of the market share.

Meanwhile, the top vendors among practices with one to three clinicians were:

Practice Fusion, with 15% of the market share among solo practices and 12% among those with up to three clinicians;

eClinicalWorks, with 9% of the market share among both solo practices and those with up to three clinicians;

Epic's ambulatory EHR system, with 5% of the market share among both solo practices and those with up to three clinicians; and

Amazing Charts, with 5% of the market share among solo practices.

Epic's ambulatory EHR system was the top product among practices with:

When the SGR bill was passed by the Senate without any ICD-10 implementation delays, the proponents of the new coding set rejoiced. Not only did passage of this bill bring about a stronger formula for Medicare reimbursements but it also meant that the ICD-10 implementation would most likely take place by the scheduled deadline of October 1, 2015.

When President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015 into law on April 16, the legislation moved American physicians away from fee-for-service payments toward value-based care and accountable care delivery, according to the Healthcare Information and Management Systems Society (HIMSS).

Additionally, the new SGR bill includes innovative objectives for establishing the meaningful use of certified EHR technology. These payment models will be key for improving population health outcomes throughout the country. The volume-based payment reductions under the prior sustainable growth rate formula will now be altered with a new annual payment update of 0.5 percent through 2019.

By 2019, doctors will be able to choose their reimbursement method among two options: the Merit-Based Incentive Payment System or the Alternative Payment Model. While the Merit-Based Incentive Payment System will depend upon the performance of physicians, doctors who choose the Alternative Payment Model must utilize certified EHR technology standards and authorized quality measures as well as assume financial risk.

The overall push toward value-based care among the federal government, patient advocacy groups, and healthcare providers will require the medical industry to quickly and efficiently transition to the ICD-10 coding set. Documenting patients’ medical histories as well as accurately reporting and coding diagnoses and treatments is vital in the quest to pay for value and enhance population health outcomes across the sector.

The Coalition for ICD-10 also reports on the importance of the ICD-10 implementation in the move toward value-based care, as ICD-9 codes do not have the same capabilities as the newer coding set. While the healthcare community supports the SGR reform bill, many physician groups are still against the ICD-10 implementation and are hoping for additional delays.

However, a move toward measuring and paying for value-based care is not possible without transitioning to a modernized form of diagnostic and procedure coding. In order to accurately measure the value of a healthcare service, it is vital to have the detail available in the ICD-10 coding set, the coalition explains.

One example of the subpar quality of ICD-9 codes involves putting two patients with similar conditions but differing symptoms under the same code while ICD-10 accounts for a variety of divergence among patients. Essentially, ICD-10 codes will include key information about patients and record their medical history more accurately with additional detail.

“Despite opposition to ICD-10 by some physician groups and a few isolated state medical societies, there is general recognition in the medical community that a modern and precise coding system like ICD-10 is essential for measuring and paying for value,” the Coalition for ICD-10 stated. “ICD-9 represents medicine of a bygone era. It cannot support a move to measuring and paying for value. To meet the demands of SGR there can be no further delays in the ICD-10 implementation date.”

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